New Patient Form

Please fill out the following medical history form.

Location:

Marital Status: Single   Married   Widowed   Divorced
Title: Mr.  Mrs.   Ms.   Miss  
Name:
Street:
City: , State:
ZipCode:
Phone (H):
Phone (W):
Phone (C):
Email:

Spouses Name:
DOB: (mm/dd/yyyy)
Patients's SS Number:
DL Number:
Parent's SS Number:
Employer:
Occuptation:
Person Financially Responsable for Account:

 
If you have insurance, what is the PRIMARY CARD HOLDER’S...
Name: SS Number: D.O.B. Employer:
Emergency Contact: Phone:
When was your last eye exam? With Dr?
How did you hear about us?
Do you wear glasses or have you ever worn glasses? Yes No
Do you need saftey eye wear for your work / hobby? Yes No
Do you wear contact lenses or have you ever worn contact lenses? Yes No
Are you interested in Laser Vision Correction surgery? Yes No
   
Tennis
Golf
Fishing
Hunting
Driving
Playing Piano/Organ
Sewing 		Boating
Reading
Woodworking/Carpentry
TV
Movies
Computer
Skeet Shooting
 
Patient's Medical History
Who is your primary care doctor? Address (city only)
Please list all medications or vitamins that you take:
Are you allergic to any medications? Yes No
If so what?

Do you use any eye drops? Yes No
If so what?
   
Make Any Where Applicable  
Heart Failure: Yes No Arthritis: Yes No
Heart Disease: Yes No Artifical Joints: Yes No
Chest Pains: Yes No Fever Blisters: Yes No
Heart Defect: Yes No Urinate more than six times daily: Yes No
Heart Surgery: Yes No Bladder problems: Yes No
High Blood Pressure: Yes No Dialysis: Yes No
Pace Maker: Yes No Stomach Ulcers: Yes No
Blood Transfusion: Yes No Hepatitis: Yes No
Anemia: Yes No Cirrhosis: Yes No
Sickle Cell Anemia: Yes No Crohn's Disease: Yes No
Hemophillia: Yes No IBS: Yes No
Leukemia: Yes No Organ Transplant: Yes No
HIV: Yes No Reflux Disease: Yes No
Stroke: Yes No Hay Fever: Yes No
Hearing Loss: Yes No Sinus Problems: Yes No
Earaches: Yes No Asthma: Yes No
Migraines: Yes No Bronchitis: Yes No
Dizzy Spells: Yes No Emphysema: Yes No
Epilepsy: Yes No Tuberculosis: Yes No
Psychiatric Treatment: Yes No Kidney stones: Yes No
Brain Injury: Yes No Sexually transmitted disease: Yes No
Cancer: Yes No Drink Alcohol: Yes No
Thyroid: Yes No Smoke: Yes No
Skin Rash or Hives: Yes No Pregnant: Yes No
 
List any other health problems of your immediate family.
 
I authorize this office to release any information necessary to expedite insurance claims. I understand that I am responsible for all charges, regardless of insurance coverage.
Signature
Date (mm/dd/yyyy)